Topics In Geriatrics: Manual Therapy for LBP in the the Aging Adult
Purpose:
Manual therapy is a widely used intervention amongst multiple professions for a variety of orthopedic and neurological conditions. However, often times in clinical practice, certain treatments are withheld from the geriatric population due to perceived risks, rather than actual risks. This overview will attempt to provide clarity of the risks and efficacy of the benefits associated with manual therapy for the older adult.
Objectives:
Outline the general indications/contraindications to the use of manual therapy
Outline the indications/contraindications for the use of manual therapy in the geriatric population, regardless of setting
Provide evidence for the benefits of manual therapy to address LBP
Provide evidence for specific techniques and interventions utilized in current research
Contraindications to Manual Therapy (Rushton 2012)
Multi-level nerve root pathology
Worsening neurological function
Unremitting, severe, non-mechanical pain
Unremitting night pain (preventing patient from falling asleep)
Relevant recent trauma
Upper motor neuron lesions
Spinal cord damage
Precautions to Manual Therapy (Rushton 2012)
Local infection
Inflammatory disease
Active cancer
History of cancer
Long-term steroid use
Osteoporosis
Systemically unwell
Hypermobility syndromes
Connective tissue disease
A first sudden episode before age 18 or after age 55
Cervical anomalies
Throat infections in children
Recent manipulation by another health professional
Red Flag Screening: (Delitto 2012)
Compression Fracture
History of major trauma, minor trauma age > 50, pain and tenderness over lumbar segment, female
Infection
Higher Risks: Recent bacterial infection, IV drug use, long term corticosteroid use, immune-suppressive individuals
Fever/chills/fatigue
Local tenderness over SP and Spinal percussion painful
Tumor
Constant/unaffected by position, age >50, history of Cx, failure of conservative intervention, unexplained weight loss, no relief with bed rest
Cauda Equina
Urine retention, fecal incontinence, saddle anesthesia, sensory/motor deficits in L4/L5/S1
AAA
PVD/CAD/Associated risk factors, Age >70, Palpation of abnormal aortic pulse (4cm)
Sensation (dermatome)
Strength (myotome)
Reflexes
DTRs
Inverted Supinator
Hoffman’s
Babinski’s
Cranial Nerve Exam
Geriatric Considerations:
Osteoarthritis (OA) vs. Rheumatoid arthritis (RA)
Literature strongly supports the use of manual therapy (MT) for the treatment of OA, but does not currently support MT for RA.
Osteopenia vs. Osteoporosis
The risk for fracture varies considerably, with osteoporosis being higher than osteopenia. However, there are no absolutes, and the use of MT should be determined on an individual basis using a cluster of findings.
Spinal Manipulation Safety (Oliphant 2004)
The risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH has been calculated to be less than 1 in 3.7 million manipulations
If "significant complications“ occur in 1% to 4% of NSAID users, in 1.5% to 12% of LDH surgeries, and in one in 3.7 million patients receiving spinal manipulation for LDH, then spinal manipulation is at least 37,000 to 148,000 times safer than NSAIDs and 55,500 to 444,000 times safer than surgery for the treatment of LDH.
Treatments and Evidence
Physical Therapy Clinical Practice Guideline for LBP (Delitto 2012)
“Clinicians should consider utilizing thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain. Thrust manipulative and non- thrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with sub acute and chronic low back and back-related lower extremity pain. (Recommendation based on strong evidence)”
Joint Clinical Practice Guideline from the American College of Physician and the American Pain Society (Chou 2007)
“For patients who do not improve with self care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation....”
Is There Harm In Under-treating? (Childs 2006)
Patients with LBP who received only exercise without manipulation were eight times more likely to experience a worsening in disability after 1 week and four times more likely to experience a worsening in disability at 4 weeks than patients who received manipulation
The decision not to provide manipulation for patients with LBP does not appear to be “conservative”.
Stenosis (Backstrom 2012)
Common symptoms are either unilateral or bilateral intermittent neurogenic claudication, or a combination of LE pain, tension, and weakness that occurs with walking and is relieved with sitting.
Examination of asymptomatic subjects showed that >30% had canal narrowing that would be classified as consistent with LSS (Weisel et al., 1984; Boden et al., 1990). Imaging therefore cannot be considered a gold- standard in diagnosis of LSS, and must only be considered as an adjunct to a thorough physical examination.
Treatments
Successful results were reported with techniques described as follows: flexion-distraction manipulations, sidelying lumbar rotation thrust, posterior-to- anterior mobilizations, sidelying translatoric side bending manipulations, thoracic thrusts, neural mobilizations (DuPriest, 1993; Atlas et al., 1996, 2000, 2005; Simotas et al., 2000; Snow, 2001; Whitman et al., 2003; Creighton et al., 2006; Murphy et al., 2006).
Normalization of hip motion appears to be a key element for the successful treatment of patients with LSS.
The only reported adverse events in studies using thrust or non-thrust mobilization/manipulation techniques in this population are minor, transient soreness in a small percentage of patients (Murphy et al., 2006).
Techniques include:
Sidelying transitory and rotational lumbar manipulations
Supine hip distraction manipulation
Prone hip PA mobilization
Supine hip inferior and lateral glide mobilization
Stenosis (Whitman 2006)
A greater proportion of patients in the manual physical therapy, exercise, and walking group reported recovery at 6 weeks compared with the flexion exercise and walking group (P 0.0015), with a number needed to treat for perceived recovery of 2.6.
At 1 year, 62% and 41% of the manual therapy, exercise, and walking group and the flexion exercise and walking group, respectively, still met the threshold for recovery.
Improvements in disability, satisfaction, and treadmill walking tests favored the manual physical therapy, exercise, and walking group at all follow-up points.
Techniques included:
Selection of specific manual physical therapy interventions and exercise techniques was based on the underlying impairments identified by the treating physical therapist, and included both thrust and nonthrust manipulation of the spine and lower extremity joints, manual stretching, and muscle strengthening exercises.
Chronic LBP (Burns 2011)
Eight consecutive patients with a primary report of CLBP without radiculopathy were treated with a standardized approach of manual physical therapy and exercise directed at bilateral hip impairments for a total of three sessions over approximately 1 week
Five of the eight (62.5%) patients reported ‘moderately better’ or higher on the GROC at the third session, indicating a moderate improvement in self-reported symptoms. These five individuals also experienced a 24.4% reduction in ODI scores.
Suggests that an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a plausible explanation regarding the clinical outcomes of this study.
Techniques included:
Long-axis distraction manipulation
Supine AP and inferior hip mobilizations
Prone PA hip mobilizations
Summary
Overall, the current evidence does not support different treatments for LBP in the geriatric population when compared to the general population.
Overall, treatments may need to be modified for each individual patient (slightly less force, broader contact, positioning), but a technique is never contraindicated solely due to a patient’s age.
It’s not about what you do, but how you do it!!
References
Backstrom KM, Whitman JM, Flynn TW. Lumbar spinal stenosis-diagnosis and management of the aging spine. Man Ther 2011;16:308–17. doi:10.1016/j.math.2011.01.010.
Bennell KL, Matthews B, Greig A, Briggs A, Kelly A, Sherburn M, et al. Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord 2010;11:36. doi:10.1186/1471-2474-11-36.
Childs JD, Flynn TW, Fritz JM. A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain. Man Ther 2006;11:316–20. doi:10.1016/j.math.2005.09.002.
Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med 2017;166. doi:10.7326/M16-2459.
Von Heymann WJ, Schloemer P, Timm J, Muehlbauer B. Spinal High-Velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain. Spine (Phila Pa 1976) 2013;38:540–8. doi:10.1097/BRS.0b013e318275d09c.
Proximal PP, Supplement PP, Powers CM, Bolgla L a, Callaghan MJ, Collins N, et al. Patellofemoral Pain: Proximal, Distal, and Local Factors, 2nd International Research Retreat. J Orthop Sports Phys Ther 2012;42:1–55. doi:10.2519/jospt.2012.0301.
Roger Chou, Amir Qaseem, Vincenza Snow, Donald Casey TC, K. PS and DKO. Clinical Guidelines Diagnosis and Treatment of Low Back Pain : A Joint Clinical Practice Guideline from the American College of Physicians and the American. Ann Intern Med 2007;147:478–91.
Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, et al. A Comparison Between Two Physical Therapy Treatment Programs for Patients With Lumbar Spinal Stenosis. Spine (Phila Pa 1976) 2006;31:2541–9. doi:10.1097/01.brs.0000241136.98159.8c.
Wong JJ, C??t?? P, Sutton DA, Randhawa K, Yu H, Varatharajan S, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain (United Kingdom) 2017;21:201–16. doi:10.1002/ejp.931.
Additional References
Beattie PF, Butts R, Donley JW, Liuzzo DM. The within-session change in low back pain intensity following spinal manipulative therapy is related to differences in diffusion of water in the intervertebral discs of the upper lumbar spine and L5-S1. J Orthop Sports Phys Ther 2014;44:19–29. doi:10.2519/jospt.2014.4967.
Beattie PF, Arnot CF, Donley JW, Noda H, Bailey L. The Immediate Reduction in Low Back Pain Intensity Following Lumbar Joint Mobilization and Prone Press-ups Is Associated With Increased Diffusion of Water in the L5-S1 Intervertebral Disc. J Orthop Sport Phys Ther 2010;40:256–64. doi:10.2519/jospt.2010.3284.
Cecchi F, Molino-Lova R, Chiti M, Pasquini G, Paperini A, Conti AA, et al. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Clin Rehabil 2010;24:26–36. doi:http://dx.doi.org/10.1177/0269215509342328.
Childs MJD, Fritz JMJ, Flynn TTW, Irrgang JJ, Johnson MKK, Childs J, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141:920–8. doi:10.7326/0003-4819-141-12-200412210-00008.
Cook CE, Showalter C, Kabbaz V, O’Halloran B. Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain? Man Ther 2012;17:325–9. doi:10.1016/j.math.2012.02.020.
Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, et al. A Clinical Prediction Rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976) 2002;27:2835–43. doi:10.1097/00007632-200212150-00021.
JA C, JM F, Kulig K, TE D, Eberhart S, Magel J, et al. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Spine (Phila Pa 1976) 2009;34:2720–9. doi:http://dx.doi.org/10.1097/BRS.0b013e3181b48809.
Purpose:
Manual therapy is a widely used intervention amongst multiple professions for a variety of orthopedic and neurological conditions. However, often times in clinical practice, certain treatments are withheld from the geriatric population due to perceived risks, rather than actual risks. This overview will attempt to provide clarity of the risks and efficacy of the benefits associated with manual therapy for the older adult.
Objectives:
Contraindications to Manual Therapy (Rushton 2012)
Precautions to Manual Therapy (Rushton 2012)
Red Flag Screening: (Delitto 2012)
Geriatric Considerations:
Treatments and Evidence
Physical Therapy Clinical Practice Guideline for LBP (Delitto 2012)
Joint Clinical Practice Guideline from the American College of Physician and the American Pain Society (Chou 2007)
Is There Harm In Under-treating? (Childs 2006)
Stenosis (Backstrom 2012)
Stenosis (Whitman 2006)
Chronic LBP (Burns 2011)
Summary
References
Backstrom KM, Whitman JM, Flynn TW. Lumbar spinal stenosis-diagnosis and management of the aging spine. Man Ther 2011;16:308–17. doi:10.1016/j.math.2011.01.010.
Bennell KL, Matthews B, Greig A, Briggs A, Kelly A, Sherburn M, et al. Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord 2010;11:36. doi:10.1186/1471-2474-11-36.
Childs JD, Flynn TW, Fritz JM. A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain. Man Ther 2006;11:316–20. doi:10.1016/j.math.2005.09.002.
Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med 2017;166. doi:10.7326/M16-2459.
Von Heymann WJ, Schloemer P, Timm J, Muehlbauer B. Spinal High-Velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain. Spine (Phila Pa 1976) 2013;38:540–8. doi:10.1097/BRS.0b013e318275d09c.
Proximal PP, Supplement PP, Powers CM, Bolgla L a, Callaghan MJ, Collins N, et al. Patellofemoral Pain: Proximal, Distal, and Local Factors, 2nd International Research Retreat. J Orthop Sports Phys Ther 2012;42:1–55. doi:10.2519/jospt.2012.0301.
Roger Chou, Amir Qaseem, Vincenza Snow, Donald Casey TC, K. PS and DKO. Clinical Guidelines Diagnosis and Treatment of Low Back Pain : A Joint Clinical Practice Guideline from the American College of Physicians and the American. Ann Intern Med 2007;147:478–91.
Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, et al. A Comparison Between Two Physical Therapy Treatment Programs for Patients With Lumbar Spinal Stenosis. Spine (Phila Pa 1976) 2006;31:2541–9. doi:10.1097/01.brs.0000241136.98159.8c.
Wong JJ, C??t?? P, Sutton DA, Randhawa K, Yu H, Varatharajan S, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain (United Kingdom) 2017;21:201–16. doi:10.1002/ejp.931.
Additional References
Beattie PF, Butts R, Donley JW, Liuzzo DM. The within-session change in low back pain intensity following spinal manipulative therapy is related to differences in diffusion of water in the intervertebral discs of the upper lumbar spine and L5-S1. J Orthop Sports Phys Ther 2014;44:19–29. doi:10.2519/jospt.2014.4967.
Beattie PF, Arnot CF, Donley JW, Noda H, Bailey L. The Immediate Reduction in Low Back Pain Intensity Following Lumbar Joint Mobilization and Prone Press-ups Is Associated With Increased Diffusion of Water in the L5-S1 Intervertebral Disc. J Orthop Sport Phys Ther 2010;40:256–64. doi:10.2519/jospt.2010.3284.
Cecchi F, Molino-Lova R, Chiti M, Pasquini G, Paperini A, Conti AA, et al. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Clin Rehabil 2010;24:26–36. doi:http://dx.doi.org/10.1177/0269215509342328.
Childs MJD, Fritz JMJ, Flynn TTW, Irrgang JJ, Johnson MKK, Childs J, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141:920–8. doi:10.7326/0003-4819-141-12-200412210-00008.
Cook CE, Showalter C, Kabbaz V, O’Halloran B. Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain? Man Ther 2012;17:325–9. doi:10.1016/j.math.2012.02.020.
Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, et al. A Clinical Prediction Rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976) 2002;27:2835–43. doi:10.1097/00007632-200212150-00021.
JA C, JM F, Kulig K, TE D, Eberhart S, Magel J, et al. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Spine (Phila Pa 1976) 2009;34:2720–9. doi:http://dx.doi.org/10.1097/BRS.0b013e3181b48809.